Has a divide developed between physicians and patients regarding routine screening mammograms?
Apparently, if the results of an online survey described this week in an editorial in the Annals of Internal Medicine are to be believed.
As widely (and sometimes hysterically) reported last fall, the U.S. Preventive Services Task Force (USPSTF) has updated its breast-cancer screening guidelines, essentially recommending that most women don’t need routine mammograms until age 50 and that a mammogram every other year is sufficient after that.
Those guidelines, like many other USPSTF recommendations and reviews, were first published in the Annals.
Despite all the attempts to discredit the USPSTF’s breast cancer screening task force, it seems that some people were persuaded by its reasoning and evidence.
And, according to the 651 people who responded to the Annals’ survey, those people are more likely to be medical professionals than patients.
Some 62 percent of the respondents to the survey were health-care providers (mostly physicians). Of them, about two-thirds said that they intended to stop offering routine mammograms to women in their 40s and to start recommending every-other-year mammograms to women aged 50 to 74.
But they’re going to meet with resistance from women, if the Annals’ admittedly unscientific survey can be believed. Some 71 percent of the women who responded to the survey said they were very or somewhat unlikely to either give up routine mammograms in their 40s or switch after age 50 to less frequent screening, no matter what their physicians recommended.
An emotional topic
Breast cancer is, understandingly, an emotional topic. But, as the editorial in the Annals notes, the “outcry” over the USPSTF’s recommendations “shocked many.”
Probably few people were more stunned than the Annals’ editors themselves, who were angrily — and unfairly — attacked by politicians, interest groups, and others for releasing the guidelines during last fall’s heated debate over the now-stuck health-care-reform bill. (In the current issue, the editors explain that the timing of the publication of the USPSTF’s guidelines had nothing to do with politics, but everything to do with the journal’s complex, many-months-long editorial process.)
The editors note that they — and the Task Force members themselves — had no reason to anticipate the “media cacophony” that followed the publication of the guidelines:
Over the past decade, Annals has peer-reviewed and published more than 50 USPSTF recommendation statements and background review. Although prevention is vital to public health, none of the previous guidelines grabbed the public’s attention as much as the Task Force’s recommendations….
For example, although depression is far more common than breast cancer, the Task Force’s December 2009 recommendations that advised against routine depression screening in the many primary care settings where depression care supports are not in place were met with relative silence. Yet, the media and politicians presented the breast cancer screening recommendations as a major departure from existing guidelines that heralded an age of rationed care in the United States. Confusion, politics, conflicted experts, anecdote, and emotion ruled front pages, airwaves, the Internet, and dinner-table conversations.
No simple answers
As the editorial also points out, it’s difficult to be dispassionate about breast cancer when almost all of us knows — or is — someone whose cancer was found on a mammogram. Yet the issue is much more complex than suggested by the slogan “early screening saves lives,” as the Annals’ editors explain:
Many perceive that the mammogram ‘saved a life.” Unfortunately, only a fraction of abnormalities initially detected on mammography and subsequently treated truly represents a life saved rather than unnecessary or premature treatment. Sadly, it is also true that many women who have cancer detected by screening succumb to the disease despite early detection and treatment.
Furthermore, despite evidence that offering mammography screening to women reduces breast cancer mortality, it may not reduce all-cause mortality — an important outcome that encompasses both benefits and unintended risks of screening.
Breast cancer prematurely claims the lives of many, but it is wrong to mislead women about the effectiveness of current screening methods. Women deserve to make decisions about screening for breast cancer armed with the best available information about potential benefits and harms.
The editors also warn against letting politicians and special interests derail the Task Force’s “charge to provide evidence-based, population-level guidance”:
Because the USPSTF issued recommendations that were politically unpopular among some constituents, there have been calls to curtail this independent body’s work. If the USPSTF sinks in turbulent waters whipped up by emotion, anecdotes, and politics, Americans should mourn its loss.
